Applicant Product Submittal Form

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APPLICANT PRODUCT SUBMITTAL FORM

Process Media Classification to ANSI/NSF Standard 61

Do you have a current UL File for this submittal?

/ YES / Please provide File, Volume, and Section Info and
Indicate any changes to Company Info, below / UL File #: / Volume, Section:
NO / Please complete the Company Information, below

COMPANY INFORMATION

APPLICANT:The company or individual who applies to UL for the investigation of a component, product or system. This party contractually assumes the financial obligation for the cost of the investigation and Follow-Up Service, and thereby exercises the rights to information obtained as a result of the investigation.

COMPANY NAME:

STREET ADDRESS:
CITY, STATE:
PROVINCE, COUNTRY:
CONTACT NAME/TITLE:
TELEPHONE: /

FAX:

/

EMAIL:

CLASSIFIED COMPANY:The company under which the Applicant wishes the Classification of a certified product to appear in UL’ s published records (i.e., the name of the company under which the product is sold)
Classified Company Info is same as Applicant Info / Alternate Classified Company (Classified Company different from Applicant) / Multiple Classified Companies (Applicant and Additional Classified Company)
COMPANY NAME:
STREET ADDRESS:
CITY, STATE:
PROVINCE, COUNTRY:
CONTACT NAME/TITLE:
TELEPHONE: /

FAX:

/

EMAIL:

MANUFACTURER:The company responsible in full or in part for manufacturing the product submitted to UL for certification, including but not limited to its compounding, molding, production in final form, packaging and labelling. A facility that repackages and re-labels a product is also considered a Manufacturing location.
Mfr Info is same as Applicant Info / Mfr Info is same as Classified Company Info / New Manufacturer/ Location / Alternate Manufacturer/ Location
Please Provide any Additional Manufacturing Location Info on Separate Page

COMPANY NAME:

STREET ADDRESS:
CITY, STATE:
PROVINCE, COUNTRY:
CONTACT NAME/TITLE:
TELEPHONE: /

FAX:

/

EMAIL:

AGENT: A third party authorized to represent the Applicant in dealings with UL. Please note an agent must have an active Agency Authorization on file.
AGENCY NAME: / AGENCY CONTACT:
TELEPHONE: /

FAX:

/

EMAIL:

UL will refrain, without the Applicant’s prior written authorization, from voluntarily disclosing to third parties proprietary information which is obtained by UL in confidence from the Applicant and which is not already known to UL, already available to the public or subsequently acquired from other sources.

Applicant / Page 1 of 5 / «VariationNumber»
Issued: January 5, 2005

Return completed form to :

Underwriters Laboratories Inc.- Attn: Mary Risper, Customer Service – 333 Pfingsten Road , Northbrook, IL 60062

Telephone: (847) 664-4911 Fax (847) 574-4005 Email:
Applicant / Page 1 of 5 / «VariationNumber»
Issued: January 5, 2005

GENERAL PRODUCT INFORMATION – PART 1

PROCESS MEDIA
PRODUCT NAME:
Catalog number, model number, trade name, etc. under with the product is sold. This will be the product designation under which UL will list this product in its published records.
GENERAL PRODUCT TYPE:
Ion Exchange
Adsorption
Oxidation
Aeration
Filtration
/
Other (Please specify)
PRODUCT LINE SIZE RANGE(where applicable):
Applicant / Page 1 of 5 / «VariationNumber»
Issued: January 5, 2005

GENERAL PRODUCT INFORMATION – PART 2

METHOD OF MANUFACTURE
Give a brief description of the process involved in each stage of manufacture of this product. Please specify the designation (trade name, model number, etc) and supplier (name and address) of each manufacturing aid, such as a mold release agent, a lubricant, or an adhesive that is used, if it is not specified in the formulation provided on page 5. For molded parts, please specify molding parameters (time, temp, pressure). If more than one manufacturing location is involved, indicate the location(s) where each manufacturing step occurs.
APPLICATION INFORMATION
Please enclose product literature containing use and installation instructions, technical data sheets and other relevant application information, and indicate below the type of literature enclosed.
Literature enclosed:
Applicant / Page 1 of 5 / «VariationNumber»
Issued: January 5, 2005

SUPPLIER INFORMATION

Please provide contact information for each supplier listed on the Raw Material / Component Information Page

NAME OF SUPPLIER / ADDRESS / CONTACT INFORMATION
(PHONE NUMBER, FAX, EMAIL) / CONTACT NAME
Applicant / Page 1 of 5 / «VariationNumber»
Issued: January 5, 2005

RAW MATERIAL / COMPONENT INFORMATION

PRODUCT NAME: / Page / of

Please list all individual raw materials/components (i.e. catalysts, processing aids, additives, etc.) used to manufacture the specified product.

If there is more than one supplier for each raw material/component, list each separately. Make copies of this page if necessary.

THIS TABLE MUST BE FILLED OUT COMPLETELY TO TOTAL 100%

RAW MATERIAL /
COMPONENT NAME * / CHEMICAL DESCRIPTION AND/OR FORMULA / CAS NUMBER / ROLE OF MATERIAL / WEIGHT/VOLUME/
% COMPONENT IN FINAL PRODUCT / APPROVALS** / SUPPLIER
* Attach supplier technical brochures, MSDS, etc. for each raw material/component if available
** Attach documentation of Certificate of Analysis or Regulatory Approvals (i. e., supplier certification of FDA status, EPA, MCL value, UL/NSF certification letters, etc.)
I hereby certify that all information in this document is accurate and complete to the best of my knowledge. The information submitted may be accessed by UL staff in support of projects for
other Applicants whose products contain this raw material/component. / RETURN THIS FORM TO:
Mary Risper, Customer Service
333 Pfingsten Road, Northbrook, IL 60062
Phone: (847) 664-4911
Fax: (847) 574-4005
Email:
Supplier Name / Supplier Signature/Date
Company Name / Title
Applicant / Page 1 of 5 / «VariationNumber»
Issued: January 5, 2005